0111-243 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I 'am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and•effect.
License # Lic. Class y Exp. Date.
Date" r�� �+� Signature of Contractor
' •OWNER-BUILDER.DECLARATION •
I hereby affirm under penalty of perjurythat I am exempt from the Contractor's
License Law for the following reason: 4 ^
( ) ' I, as owner of the property,' or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).'
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 'I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under,penalty of perjury one of the following declarations:
O I have and will maintain a certificate of.consent to self -insure for workers'
Compensation, as, provided for by Section 3700 of the Labor Code, for the
performance. of the work for which this permit is issued.
( ) 't have and will maintain workers' compensation insurance, as required by
Section 3700 .of the Labor Code, for the performance of the work for which this
permit is. issued. My workers' compensation insurance carrier & policy no. are:
Carrier STA EFpolicy No.
(This, section need not be completed, if the permit valuation is for•$100.00 or less).
(•) J certify that in the performance of the work for which this permit is issued;
I shall not employ any person in any manner so as to become subject to the.
workers' compensation. laws of California, and agree that if I s uld become'
subject to the workers' compensatio.n•pr vovo i .ions of Section,3700 f the Labor
Code, I shall+forthwith cornply with those provisions.
Date:.°" �� Applicant y
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000;: ih.
addition to the cost of compensation, damages as provided for in Section* 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a' permit .subject to the ,conditions and restrictions set forth on this
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for, whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify,
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if .
work is not •commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, 'and hereby authorize -representatives of this City to enter. upon
the above-mentioned property`for inspection purposes.01
Signature (Owner/Agent) Date L,
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.1.1-243 TRACT 4:
294P
JOB SITE `--^ = •• ti•
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ADDRESS *`3,0wynk #:snmu&
OWNER
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79.295 Rt ti'AE 01100 LA QY-pi rA IARC.
:1,AQU1 I -A CA 92253
LAQUIN7iA CA 92253:
(760)771-1941 CHIP 29%
USE OF PERMIT
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P004SPAOR DRIVEWAY APPR°,OACF$
CUOTOM C:C'x3S'1'1 UCTION 035.00 sp
PO.RC`•KWATIO 1617.0 SIF
0P,1 A01?lCATtP0JkT 614.00 OF
X&IMMD C'C ST OF C:O:11i:'s32'�J•f.`",i('�ION
220A.52100
l�a:aa: 9VMr,R:�
0,0143MUC!'ION ME 101-000-418-000 �l6t1s?9.I1t3
K-A'AI t f1WK FEE 101.y.000-4:39-1-218
MEC'HAVIC .L ROM ` 01.000.421�000 sto.5.00
P,I, +�C,"€ WC AL PUB 101,.000-420-000 a�. ti!
PI.41MOTMO 3' E. 1 0 1-0004 1 MOO $17%25
S'1`. CM0 010ION 11HE. 1?MID -161-000-241 -000 $22.04
GRADING WE 920,60
EMVK1.,0P1F2 IMPACT, F&.E, $D,9fl7.Obt
ART M 19UB1. C 1 IALCES HoU-11270-000-445-MV
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D,EC 0 e 2n1
C YGRAQUORTA
RECEIPT
DATE• f
/ - f
f
BY
DATE FINALED
INSPECTO
�,A/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-Z - Z
Ducts
Slab Grade
_
Z
Return Air
Steel
a Z - Z
Combustion Air
Roof Deck
_
p
Exhaust Fans
_
O.K. to Wrap
_Zs -d
F.A.U.
Framing
-vZ
Compressor_
_
Insulation
- $ -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
�%�/
Fans & Controls
Party Wall Insulation
_
/�`
Condensate Lines
Party Wall Firewall
_ _
Exterior Lath
Drywall - Int. Lath
'
Final
Final
0
POOLS -SPAS'
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines �j'
-/ ? - ?� ��
Heater Final
Water Piping
_ _
Plumbing Final
Plumbing Top Out
_
/ �2
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)-,--
-�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
vp
Lcw Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
j�l _